Paradigms of Diet in Type 1 Diabetes #ISPAD2021 S1E3

 

Dietary recommendations for children with diabetes are based on healthy eating recommendations suitable for all children and adults and therefore, the whole family. Nutritional advice must be adapted to cultural, ethnic, and family traditions and the psychosocial needs of the individual child. Likewise, the choice of insulin regimen should take into account the dietary habits and lifestyle of the child, as suggested by (ISPAD, 2018).

Structured Eating: Current Recommendations

International Society for Pediatric and Adolescent Diabetes:

·         Implementation of an individualized meal plan with prandial insulin adjustments improves glycemic control

·         Matching of insulin dose to carbohydrate intake on intensive insulin regimens allows greater flexibility in carbohydrate intake and mealtimes, with improvements in glycemic control and quality of life. Meal-time routines and dietary quality are important for optimal glycemic outcomes.

Diabetes Canada:

·         Consistency in spacing and intake of carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight.

American Diabetes Association:

·         General guidance for individualized strategies to match insulin to food

·         Meal time consistency is not addressed

NB. It’s possible, that too much flexibility in the timing of consumption of food may actually hinder glycemic control and appropriate insulin dosing, rather than helping. 

SPAD Clinical Practice Consensus Guidelines 2018: Aims of nutritional management

·         Three meals a day incorporating a wide variety of nutritious foods from all food groups, with appropriate healthy snacks (if necessary), will supply all essential nutrients, maintain a healthy weight, prevent binge-eating and provide a framework for regular monitoring of blood glucose levels and supervision of insulin doses (as required);

·         Provide sufficient and appropriate energy intake and nutrients for optimal growth, development, and good health. Avoid restrictive diets as they may result in poor growth, nutrient deficiencies, and increased psychosocial burden;

·         Achieve and maintain an appropriate Body Mass Index and waist circumference. This includes the strong recommendation for children and young people to undertake regular physical activity.

·         Achieve a balance between food intake, metabolic requirements, energy expenditure, and insulin action profiles to attain optimum glycemic control.

·         Reduce the risk of micro and macro-vascular complications, particularly cardiovascular disease.

Consequences of Too Much flexibility in Dietary Timing and Composition: Evidence Observational and Limited

1.    Norwegian Childhood Diabetes and Quality Project (n=550)

·         It was found out that, not skipping meals and having both breakfast and supper 6x/week was associated with lower HbA1c

2.    SEARCH for Diabetes in Youth (n=821)

·         Increased eating frequency was associated with larger increases in HbA1c over time.

3.    T1D Exchange

·         On the other hand, increased eating frequency was associated with lower HbA1c. it is however challenging, because often times eating frequency is defined in different ways and it may or may not be associated with the timing of food consumption.

 “Structured Eating” as a Dietary Strategy in T1D

Day-to-day consistency in timing and frequency of eating occasions throughout the day, with a focus on distribution of carbohydrates, could lead to:

·         More predictable glycemic response

·         More accurate insulin dosing

·         Better glycemic control

NB. Carbohydrates (CHO) type, protein and fat also impact insulin requirements

Structured Eating (SE) “Tenets”

1.    3-4 main meals and 1-2 snacks► (>15% CHO)

2.    Spacing eating occasions throughout the day► >2 and <4 hrs.

3.    Spacing carbohydrates (CHO) throughout the day►

20-35% CHO <4 hrs

20-40% CHO 4-8 hrs, 20-40% CHO 8-14 hrs

0% CHO 14+ hrs. of waking

4.    No post-dinner snacking► Last eating occasion is a meal (>15% CHO)

5.    Eating within a short period of waking (not skipping breakfast) ► eating occasion <2 hours of waking  

      Conclusion

The nutritional care of children with diabetes is complex. Diabetes management is set within the context of the family, a surrounding social system, issues of non-adherence, peer pressure, emerging independence, and the ultimate aim of maintaining the quality of life. Moreover, it is possible to improve diabetes outcomes through attention to nutritional management and an individualized approach to education.

Reference

1.    Elizabeth Mayer-Davis, PhD

2.    ISPAD Clinical Practice Consensus Guidelines 2018: Nutritional management in children and adolescents with diabetes